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Deciding on breast reconstruction

For a growing percentage of women, breast reconstruction provides a chance to lessen the psychosocial and physical adjustments following a mastectomy. The Michigan study is unique because it is the first time such a large number of patients from so many centers were surveyed before and after their surgery. The chances of a biased interpretation are markedly decreased because of the large number of participating surgeons. The most interesting thing was, among the group undergoing immediate reconstruction, the particular procedure used made little difference in how women felt about themselves and their bodies afterward.

Results limited
This study did have some limits. It was only a one-year study. It would be interesting to see what happens three years from now-if any of the implants leaked or if there are other changes. Researchers also did not address the women who chose not to undergo any form of reconstruction after mastectomy. It would be useful to have included such a group for comparison of psychosocial measures. There are always problems inherent in studies based on surveys that rely on patient impressions and judgments.

Radiation rules out reconstruction
Not every reconstruction procedure is available to every woman. For example, if a woman expects to have radiation therapy after mastectomy, implants are not a good option. Radiation can cause the skin near the implant to contract, leading to a poor looking result. Chemotherapy generally has no such effect on an implant, but a woman may still need to wait. The TRAM procedure might tolerate radiation therapy better, since natural tissue is used. However, lately there's been discussion that problems have later arisen with TRAM after radiation as well.

Understanding implants
The simplest procedure is the expander/implant method. After the breast is removed, a tissue expander is placed under the skin and muscle at the time of surgery. For this reason, this procedure is called "immediate" reconstruction, though it's really a misleading term because it generally takes awhile for the procedure to be completed.

The expander is filled with saline solution (salt water) over several months, allowing the skin to slowly stretch, making room for the implant. At a later date, the expander is exchanged for the implant and the procedure is complete. Several factors limit its use:

• Does not work well with radiation therapy
• Frequent visits to the surgeon's office are needed
• Some patients may not tolerate the expander
• Possibility of leaks or infections

Some say the results are not as natural. However, for a patient who does not want to or cannot medically undergo the more complex TRAM procedure, it can provide a very acceptable solution.

TRAM procedures
TRAM procedures use tissue taken from the woman's own body to reconstruct a breast mound. The tissue is living and therefore may better resemble a natural breast. Since either type of TRAM can be performed the same day as a mastectomy, they are truly immediate reconstructions. However, the surgery is complicated and recovery is long.

In a pedicle TRAM, a cut is made almost all around the transverse rectus abdominis muscle in the lower abdomen. The tissue remains attached via blood vessels to the abdomen and is repositioned through a cut in the skin at the site of the removed breast. Problems can arise if the blood supply to the relocated tissue is cut off. If this happens, part or all of the moved tissue will die off and have to be removed. Sometimes, two blood vessels (from both rectus muscles) are used to prevent this problem, but this creates other difficulties. For a woman who completely understands what's involved, the results can be excellent and this type or reconstruction can tolerate radiation better than an implant.

With a free TRAM, the muscle is completely removed from the abdomen, then its blood vessels are reattached to new blood vessels higher up in the chest. This is very sophisticated microsurgery that requires special expertise. There remains a chance that the blood supply will be cut off, but the chance of the repositioned tissue dying is thought to be less. This might be a good procedure for a woman who cannot undergo the pedicle flap procedure because of scar tissue from previous surgeries or if she is a smoker. Smokers have a higher incidence of the tissue dying off.

Before you decide
A woman about to undergo a mastectomy is under a tremendous deal of emotional and physical stress. It's important that any decision be made after a consultation with a qualified plastic surgeon who has experience performing breast reconstruction and can outline all the factors in advance.

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Dr. Narayan is a plastic surgeon at Yale-New Haven Hospital with a special interest in cancer surgeries and an assistant professor of surgery at Yale University School of Medicine.